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Consent Agreement for Provision of Chronic Care Management

Please review and initial below.

By initialing this Agreement, you consent to Bloom Healthcare (referred to as “Provider”), providing chronic care management services (referred to as “CCM Services”) to you as more fully described below.

CCM Services are available to you because you have been diagnosed with two (2) or more chronic conditions which are expected to last at least twelve (12) months and which place you at significant risk of further decline.

CCM Services include 24-hours-a-day, 7-days-a-week access to a health care provider in Provider’s practice to address acute chronic care needs; systematic assessment of your health care needs; processes to assure that you timely receive preventative care services; medication reviews and oversight; a plan of care covering your health issues; and management of care transitions among health care providers and settings. The Provider will discuss with you the specific services that will be available to you and how to access those services.

Provider's Obligations When providing CCM Services, the Provider must:

  • Explain to you (and your caregiver, if applicable), and offer to you, all the CCM Services that are applicable to your conditions.
  • Provide to you written or electronic copy of your care plan upon request.
  • If you revoke this Agreement, provide you with a written confirmation of the revocation, stating the effective date of the revocation.

    • Beneficiary Acknowledgment and Authorization By initialing this Agreement, you agree to the following:

  • You consent to the Provider providing CCM Services to you.
  • You authorize electronic communication of your medical information with other treating providers as part of coordination of your care.
  • You acknowledge that only one practitioner can furnish CCM Services to you during a calendar month.
  • You understand that cost-sharing will apply to CCM Services, so you may be billed for a portion of CCM Services even though CCM Services will not involve a face-to-face meeting with the Provider.

    • Beneficiary Rights You have the following rights with respect to CCM Services:

  • The Provider will provide you with a written or electronic copy of your care plan.
  • You have the right to stop CCM Services at any time by revoking this Agreement effective at the end of the then-current month. You may revoke this agreement verbally (by calling 303.993.1330) or in writing to (10900 W 44 th Ave, Suite 200, Wheat Ridge, CO 80033). Upon receipt of your revocation, the Provider will give you written confirmation (including the effective date) of revocation.
  • If the name listed below is incorrect do not sign this form. If you would like to receive a new form with a different doctor, other healthcare professional, or medical group practice listed, please call Bloom Healthcare at (720) 923-1302 to request a new form. Completing and returning this form is voluntary. It won’t affect your Medicare benefits.
    • Additional Services
    Chronic Care Management
    Palliative Care
    Dementia Care
    Care Transitions
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    See What Our Patients Have To Say

    “ Michelle Jenkins has been my mother’s primary care provider for the past 3+ years. Her attention to detail, the communication and follow up she provides and her thorough understanding of my mother’s needs is remarkable. She clearly cares about Mom and it shows! ”

    ~ Chuck F.

    “ We couldn’t be better taken care of than we are at Bloom! We are so grateful and thankful to be under their care. Our provider is the best! ”

    ~ Mr. & Mrs. F.

    My aging mother was falling through the cracks, in and out of assisted livings, rehabs after falls etc. I found Bloom and they came in and stabilized all! John and Angela as PA's were so caring and thorough. The staff at Bloom was so responsive, answering all questions promptly, and explaining things well to my mom. We were able to keep my mom home for awhile, but as she aged Bloom followed her to assisted living and beyond with an amazing continuum of care. I highly recommend Bloom, they are a great teammate in caring for our seniors, and a great resource especially during days of Covid!!

    ~ Susan G

    Bloom is an incredible organization. They provide high quality care to patients and particularly serve those patients living alone at home or those living in a senior living community. The Bloom Team is empathetic and compassionate and always work towards treating the whole patient and takes into consideration the patient’s living environment and social dynamics. The Team also works diligently to collaborate with other providers and services involved in the care of those patients. The patient is always their priority. Thank you for all you do Bloom!

    ~ Jim M.

    Since moving my mother to assisted living we have been using Bloom Healthcare to manage her care. She can still go see specialists as needed but Bloom has been wonderful to work with. I can always call for a concern and they follow through doing blood work or x-rays in her room then calling in needed prescriptions. They manage her med refills, and oversee her care at a level that brings me much peace. They are good at keeping me informed of what is needed and happening for my mother. Thank you!!

    ~ Marjie C
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    Bloom Healthcare nurses discussing plans for patients
    Bloom Healthcare doctor going over results with patient
    Bloom Healthcare Physicians meeting and discussing plans
    Bloom Healthcare physician checking patients heart rate
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